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Ctvt;:t:r-'ti:Wt!AT.tt-t3'tfi.tvty.kv.R_*kv-tt.ty-tfi.tfi.ki,tWty.t�-t Wt�-ty- <br />APPLIC ON FOR PERMIT SIN JOAQUIN LOCAL HEALTH STRICT t: <br />g UNDERGROUND TANK t: 1401 E HAIMON ATE.,`'SfOCKTON CAT: <br />CLOSURE OR /IINDONMBIT D Telephone (2091 440-3420 t: <br />t.tt.t2.tfi.tt-tfi.tfi.ty.t:'kfi.kfit-ty.tfi-kVR:ty-tfi.t;.RAT W.tv.tfi-kfi.tgtVtk.tt-ty.tVtfi.R:ty. <br />APPLICATION FOR PERMANENT/tEMPORIRY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAIIRDOUS SUBStINCES STORAGE FACILITY <br />THIS PERMIT RIPIRES 90 DIPS ?ROM THE APPROVAL DATE. DO NOT 11176 IN 111 SHARD AREAS. INDICATE PERMIT TYPE BRLOV: <br />REMOVAL IRMPORARY CLOSURE ABANDONMENT IN PLICE <br />EPA SITE 1 PROJECT CONtICT t TELEPHONE 1 — <br />Y FACILITY NAME c PHONE 1 _ �, <br />A - <br />C IDDRESS 3s <br />S �. r- C <br />I <br />L CROSS STREET <br />I -- <br />t OYNER/OPRRATOR PHONE 1 <br />Y <br />C CONtRICTOR NIKE j PHONE 6 <br />I COIIRICTOR ADDRESS 4 CA LIC 1 C SS <br />t _- <br />R INSURER t6TORK.COMP.1 <br />I-- — — -- <br />C PIKE DISTRICT PERMIT 1/19SPIR ' <br />t <br />0 LABORATORY NAME6 IT g PHONE 1 <br />R — . <br />SAMPLING FIRM' T C SINPLING METHOD <br />RMR�111111 <br />TANK 10 1 ?All SIVE CHEMICALS STORED CURREITLI CHEMICILS STORED PREVIOUSL <br />1_ _ <br />I 39 - I °� '� ' _L <br />o — rn -r <br />39- <br />_____ - LIST AD ZONAL YANK�gpIpNgqFORMI?IOgyN AS gWR�EgDHD®p0g1� SEPAR�ITS FORN <br />�fdMYi:d� 8i �t�:M6'M9 Pd.M9111 RIIW f <br />P _ APPROVED __IPPROTED 11111 CONDITIONS __ DISAPPROVED <br />L S PICININT 1119 CONDITIONS) <br />I PLAN MISTERS NINE <br />IPPLICINT MUST PERFORM ILL IORK IN ACCORD/NCE fill SIN JOIQUIN COUNTY ORDINANCES, 91119 LITS, AND RULES IND P.EGULIIIONS <br />OF THE SIN JOAOUII LOCAL HEALTH DISTRICT. OTHER OR LICENSED AGENT'S SIGNITURB CERTIFIES THE FOLLOVING: 11 CERTIFY THAT <br />IN THB PERFORMANCE OF THE TOOK FOR THICK ?HIS PERMIT IS ISSUED, I SKILL NOT EMPLOY ANY PERSON IN SUCH HAMMER AS TO BECON <br />SUBJECT TO VORKER'S COMP91SITION LITS OF CILIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOVIIG: 'I CERTIFY THI? IN THE PERFORMANCE OF TIIE VOR( FOR THICK ?HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO YORKER'S COMPENSATION LITS OF CALIFORNIA. <br />CALL FOR INSPECT ONS AT LEAST 40 IIOURS IN ADVANCE <br />SIGNED -DATE <br />OFFICE USE ONLY --EH 21 014 12/11 <br />SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS55SSSSSS95SSSSSSSSSSSSSSSS5SS5SSSSSSSSSSSSSS5S5SSSS5S5SSS5SSS5SS5SSSSSSSS55S5SSSS5SSS5SSS <br />S/REPS 1 COMP ! LOC CODE JOIST COD OUNT DUE) AMOUNT RCVD CX!/CASH RCTD BY 009 RCVD PERMIT 1 <br />